657

people. If adequate provision is made for the elderly,there should be only a very small residue-mostly patientswith neurological diseases.At present the mental-hospital system is developing by

trial and error. Psychiatrists and psychiatric nurses areleaving the mental hospital to work in the community,and health visitors and other community workers arecoming more freely into the mental hospital. We mustrecognise, however, that there is much anxiety due touncertainty about the future. Psychiatric nurses may bediffident about training in a mental hospital because of thenumber of senile patients. The changing character of thehospital adds to this anxiety. Rumours that some hospitalswill become a

" dumping-ground " for the chronic

patients of more active units or for geriatric patients fromlarge cities are discouraging. As new units appear in the

community, they will undoubtedly attract both nursesand psychiatrists from our present hospitals. If, at a timewhen fewer patients with a good prognosis are beingadmitted to the mental hospital, many of the staff leave towork elsewhere, deterioration within the mental hospitalwill be unavoidable.

Treatment in the mental hospital depends on the

attitudes, the expectations, and the morale of those whowork in it. Successful rehabilitation needs an atmosphereof therapeutic optimism. We have shown that an activetherapeutic regime produces worthwhile results amongadmissions and long-stay patients alike, and steadilyreduces the total number of patients in the hospital. Achange in attitude or a fall in morale, however produced,could readily refill these same empty beds.But if our present policies continue and the community

provides help in resettlement, I think that the hospitalwill continue to empty. Morale can be maintained ifnurses and doctors are able to work not only in the mentalhospital but also in the new units which will appear. Justas some hospitals. are developing a general-practitionerservice for patients who only need general-practitionercare, so there would seem to be a good case for developinga general nursing service to care for those patients, par-ticularly geriatric, for whom specialised psychiatric care isno longer appropriate.

It would, of course, be possible to fill the empty bedsat this or other mental hospitals with other patients-geriatric, subnormal, or others. But whichever type of

patient is sent, nothing will alter the serious defects ofmany of these institutions. Fundamentally they increasethe patient’s isolation, and by their very size frustrate theformation of therapeutic communities. It could be arguedthat if we must have short-stay and long-stay units whichare separate from each other, the short-stay unit should bein the present mental hospital, because short-stay patientscan usually overcome this handicap. On the other hand,the long-stay unit should be in the community, for its

patients are in greatest need of a situation where transitionfrom hospital to community life is easy. The long-staypatient leaving his ward to go to sheltered work should rubshoulders with potential landladies and potential work-mates and not, as at present, merely with other patients.

I have written this paper from experience at one

hospital, and perhaps it does not apply to others. Never-theless, discussion with colleagues suggests that manymental hospitals are now reducing the number of theirbeds, and share the problems of physical conditions andemotional attitudes which beset us here. It would seemessential that developments should be freely discussed if

we are to plan for the material needs of the future

psychiatric services and relieve the anxieties of the presentpsychiatric staff. We see slums pulled down and newhouses built; new roads replace the old. Only when theold mental hospitals are pulled down will there be theopportunity to provide a new service in keeping withpresent needs.

1. Ministry of Health, Department of Health for Scotland. Medical StaffingStructure in the Hospital Service: Report of the Joint Working Party.H.M. Stationery Office. Pp. 89. 5s.

Special Articles

MEDICAL STAFFING OF HOSPITALSTHE Joint Working Party on the Medical Staffing

Structure in the Hospital Service, set up in 1958 under thechairmanship of Sir Robert Platt, P.R.C.P., has now

reported. 1 The working party was appointed by theMinister of Health and the Secretary of State for Scotlandin collaboration with the Joint Consultants Committee,the Royal Scottish Corporations, and the Central Con-sultants and Specialists Committee.The main feature of the report is a recommendation

that the staffing structure should include a new gradebelow that of consultant. Those in this grade, to be knownas medical assistants, would normally have held a registrarpost for at least two years. Appointment would not be oflimited duration; and remuneration would be on a longincremental scale, extending high enough to make this acareer grade. Other features of the report are its insistenceon the need to make better use of consultants’ time and fortheir closer integration through the " firm " system, andon the need for help from general practitioners in thehospital system. The number of consultants is found tobe still insufficient.

DEVELOPMENT OF EXISTING STRUCTURE

The working party recalls that the Spens Committee on theRemuneration of Consultants and Specialists, which reportedin 1948, seems to have taken the view that in general the doctorsbetween house-officers and consultants would be aspiring toconsultant posts, and that these doctors should, throughouttheir service in these intermediate grades, concentrate as

trainees on one particular specialty. But, after discussions onthe committee’s report between the Health Departments andrepresentatives of the profession, the grades of senior and

junior hospital medical officer (both of unrestricted tenure)were added. A few years ago it was agreed that, pending theoutcome of the working party’s study, hospitals with largecasualty departments might be authorised to appoint a seniorcasualty officer for a term of four years on a salary scale withinthat applicable to senior hospital medical officers.

In 1950 junior registrarship ceased to be treated as essentiallya training grade for the post of consultant or senior hospitalmedical officer; and the name of this grade was changed tosenior house-officer. The next year the registrar grade ceasedto be looked on as primarily a training grade. In practice senior-house-officer and registrar appointments have commonly beenheld for longer than the one year and two years, respectively,named in the Terms and Conditions of Service. "We have been

told," says the working party, " that most regional hospitalboards keep good registrars as long as they wish to stay." Theposts are not necessarily graded according to the nature of thework: " Where difficulty is experienced in filling a house officerpost it is not uncommon for it to be transferred to the seniorhouse officer grade in the hope that the higher salary will attractapplicants."

In 1951 the normal tenure of a senior-registrar post wasextended from three to four years; and at present even this

longer limitation on tenure is in abeyance.

658

GENERAL CONSIDERATIONS

The excess of senior registrars, though now smaller,persists.

" At the same time contentions have been common that byreason of inadequacies in consultant staffing members of gradesbelow the consultant grade are undertaking consultant workand responsibility. Concurrently many non-teaching hospitalshave been unable to attract sufficient doctors to build upadequate staffs of house officers and registrars.

" In the evidence submitted to us there is a noteworthyabsence of testimony that the present structure has provedsatisfactory in all respects, or is the best that can be devised. Onthe contrary some criticism of it is expressed or implied in allthe general evidence received, though there is no unanimity onits shortcomings or on how they should be remedied."A basic question raised by the different criticisms is

whether a staffing structure designed for training in aspecialty can effectively fulfil service needs.

GENERAL PRINCIPLES

The structure must be based on consultants, who arerecognised as qualified to take full personal responsibilityfor the complete medical care of all patients in theirspecialties. The structure must further provide for: (1)doctors required to assist consultants in the day-to-daycare of their patients; and (2) doctors needing post-graduate experience and training. Whatever these assis-tants do for patients " must be done, and be openlyrecognised as being done, on behalf of and under thedirection of the consultant".Advancement from one grade to another should be

competitive; and some doctors who aspire to higherappointments will fail in the competition.

" On occasion these doctors may have become so specialisedthat this fact and their age become an obstacle to their obtainingsuitable work in their profession outside the Hospital Service.By that time their experience and skills are, however, bound tobe of such value to the Service that the structure should provideways and means by which such doctors may be retained in itand on a permanent basis where appropriate."The hospital structure should provide suitable places

for: (a) new graduates who need the hospital experiencewhich is a prerequisite to full registration; (b) doctors whowish to obtain further postgraduate experience, whether ornot they will be making their careers in the hospitalservice; and (c) suitably qualified doctors in other branches,especially general practice, to engage in hospital work forpart of their time.

CONSULTANTS

In the ten years 1950-59 the number of consultantsincreased by 37%-from 5610 to 7680. But, as the

average amount of time for which a part-time consultantis employed has increased, the amount of consultantservice increased by more than 37%.Excessive Delegation of Duties

Evidence received by the working party indicates thatwork properly belonging to consultants is being regularlydischarged by senior registrars and others; and it suggeststhat the number of consultants is still inadequate. Theworking party is satisfied that, of the several possiblereasons for this state, resistance by the Minister to pro-posals for new appointments is not one.

Ensuring that consultant work is done by consultants isnot only a matter of numbers: it is a matter of organisa-tion. Some consultant appointments entail a dispropor-tionate amount of travelling between hospitals-which istantamount to consultant time wasted. " We have also

met cases in which the consultants live so far from the

hospitals in which they are responsible for patients as tomake impossible their personal attendance in emergency."General PrinciplesThe working party lays down the following general

principles:1. All patients in the hospital service should be in the charge

of consultants.2. A consultant’s obligations are not restricted to certain

fixed sessions : he has an inescapable continuing responsibilityfor his patients (inpatients and outpatients alike) at all times,

3. Doctors below consultant rank should act as assistants tothe consultants.

4. The time that a consultant devotes to any given hospitalshould suffice to enable him to discharge his responsibilities." In hospitals largely concerned with the treatment of acuteillness, the aim should be for every inpatient to be seen by theresponsible consultant at least two or three times a week,Outpatient arrangements should be such that junior staff arenot left in sole charge, except in the occasional unavoidableabsence of the consultant."

5. Where practicable, small part-time appointments shouldbe absorbed into the duties of existing staff or, failing that,should be grouped together to form appointments for a worth.while amount of time.

6. The work of a consultant should be confined to as fewhospitals as circumstances will permit. In any event he shouldhave a main attachment to one hospital or hospital centre, andhe should live within easy reach of this.

’ 7. The duties required of each consultant should be definedprecisely in his contract.

Organisation of Consultant ServiceWhere two or more consultants in the same specialty

are employed in a single hospital there is everything to besaid for bringing them into a relationship which will

(a) facilitate continuous and effective consultant cover forall patients, and (b) have some regard, in the distributionof work, to the factor of seniority in the consultant gradeso that the younger consultants do more of the physicallymore strenuous work. Under this " firm " system, the

younger consultant carries the same clinical responsibili-ties, and has the same clinical independence, as his senior.The system can also be instituted where two consultantsare individually associated with different hospitals, pro-vided these are reasonably close to each other.Where there is need for more consultant service but

there is not scope for another consultant with responsi-bility for a substantial proportion of the beds, the needmay be met through a variant of the " firm " system,

In such a case the necessary relief might be provided byassociating with the existing consultant or consultants anotherdoctor of consultant rank, who would be appointed as a con-sultant on condition that he worked for the time being insupplementing the work of the consultants with whom he isassociated. " In essence he would become the junior partner ofa firm." He should always be given some beds as of right; andwhen a consultant vacancy arose in the hospitals in which hewas serving he would be given a full number of beds and anormal range of consultant duties.

SENIOR REGISTRARS

In some specialties (for example, mental health,radiology, and anaesthetics) the number of senior registrarsis less than the number of training posts; but in otherspecialties the number of senior registrars greatly exceedsthe number of training posts.

Undertaking the work of consultants is a vital part ofthe training process. What is wrong is that senior reps’

659

trars, or others, should be expected or permitted to under-take consultant responsibility as a matter of routine." Temporary delegation of consultant duties is permissible

only when there is available a consultant to whom the doctorperforming the delegated duties can turn for advice, e.g., whena consultant is on leave there must be another consultantavailable to whom reference can be made."

The working party denies that there is a special class ofwork which may be called " senior registrar " work. Thisis a training, and not a service, grade." We find no need to suggest any change in the work and

responsibility which a senior registrar should properly under-take. Though some consultant work must be undertaken inthe latter part of training, such work should be done underconsultant supervision and should not be performed indepen-dently, as a routine, as is often happening now."Four years’ tenure should not be regarded as a rigid

maximum or minimum.

Selection and Review

The working party recommends that the appointmentscommittees for selecting new senior registrars, whether forteaching or for non-teaching hospitals, should includerepresentatives from both classes of hospital. A reportshould be made on each new senior registrar a year afterthe start of his appointment, with a view to a firm decisionby the time he has been in the grade for eighteen monthsas to whether he is suitable for retention at the end of hissecond year.Rotation between Teaching and Non-teaching Hospitals

Senior registrars trained in teaching hospitals have hadan advantage in the competition for consultant posts overthose trained in non-teaching hospitals. Accordinglyeither all senior registrars should be trained in teachinghospitals or all senior registrars should be trained partly ineach of the two types of hospitals. The working partyfavours the latter course as the customary one. The

necessary link between the teaching and the non-teachinghospitals may best be maintained through committeesestablished by the regional boards and the boards of

governors jointly in England and Wales and by the regionalboards in Scotland. Such committees, which shouldconsist entirely of medical members, would supervisetraining arrangements, receive reports on all senior

registrars at the end of their first year of service and adviseon whether the appointment should be continued, andadvise on what course a senior registrar should take if hehas failed to gain a consultant post at the end of his fifthyear in the grade.NEEDS TO BE MET BY DOCTORS OTHER THAN CONSULTANTS

AND SENIOR REGISTRARS

The initial tenure of a house-officer, senior house-

officer, or registrar should be settled between the employ-ing authority and the doctor at the time when the

appointment is made: this should be up to one yearfor house-officers and senior house-officers and twoyears for registrars. At least twelve months’ continuousservice as a fully registered house-officer or a senior house-officer, or its equivalent, should normally be required of acandidate for a registrar appointment.The working party gathered evidence that the number

of graduates in Great Britain is expected to fall from anannual average of 1780 in 1955-60 to an annual average of1700 in 1961-64. Even now, without the 3628 doctorsfrom overseas, there would be a breakdown of staffingbelow the senior-registrar grade; and some decline in thenumber from overseas may follow the development of

postgraduate training for such doctors in their own

country.Because of the existing shortage in these junior grades,

those in them-especially those in non-teaching hospitals-are overworked. Moreover, not only the number butthe quality of candidates for appointments are not alwayssatisfactory. Notwithstanding uncertainties" on one point there can be no doubt: the Hospital Service

cannot hope to have an adequate and efficient staff of fullyregistered housemen and registrars unless reasonable prospectsof a good career in some branch of medicine can be seen by thedoctors who stay in the Service to work in these capacitiesLonger Hospital Service by Young Doctors

Ideally new entrants to general practice should havespent at least two years in the hospital service after becom-ing fully registered; and greater flexibility in arrange-ments for tenure of posts in the house-officer and registrargrades may attract prospective general practitioners.The possibilities offered by arrangements under whichprospective general practitioners split their time betweenhospital work and work as trainee assistants in generalpractice should not be overlooked.

General-practitioner’s RoleThere is scope for more help to the hospitals from suit-

ably qualified general practitioners as medical assistantswho would visit the hospital daily and supervise house-officers, and as clinical assistants at special clinics. In someinstances a general practitioner who has continued workin the hospital service might later be chosen for a consultantpost, and pursue this career concurrently with one ingeneral practice.The Need for a New GradeThe number of senior hospital medical officers, abso-

lutely and relatively to the number of consultants, declinedbetween 1953 and 1959. After hearing arguments for andagainst the retention of the S.H.M.O. grade the workingparty came to this conclusion:

" Some members of it carry full clinical responsibility...If it were to be continued otherwise than as a transitionalmeasure for making provision for those already in it majorchanges would be required: it is too near to the consultantgrade in status to be a satisfactory part of a permanent structureand we cannot therefore recommend its continuance as a

permanent feature."

This grade should be closed to new appointments.A new grade of unlimited tenure not above senior-

registrar level is required for the senior registrar who,having completed his training, does not proceed to a con-sultant appointment; for some registrars to enable themto remain in the hospital service in a position of security;and for some general practitioners. These new postsshould be a supplement, not an alternative, to measures toencourage young doctors as a general rule to stay longer inhospital work after the year of provisional registration, andto provide wider opportunities for general practitioners toassist in hospital work.Admission to the new grade should normally be re-

stricted to doctors who have held a registrar appointmentfor at least two years and have worked in the hospital ser-vice for at least three years since full registration. Appoint-ment should not be of limited duration. The work com-mon to all specialties in which the members of this grademight properly engage is work such as is done by regis-trars. All members of this grade should work as assistantsto consultants and under their supervision, except any inophthalmology who may be engaged solely on refraction.

660

The generic name of the grade should be medicalassistant, but in the specialties (other than general medi-cine in which " medical assistant " is appropriate also as aspecific name) the appointments should be known as

assistant in surgery, assistant in chest medicine, &c.Members of the grade should be recognised as potentialcandidates for consultant appointments.The suggested grade would consist of doctors with

widely varying experience; and accordingly a long incre-mental salary-scale seems to be indicated. Time-expiredsenior registrars might enter the scale at a point thattook account of the salary they had received as seniorregistrars. " For recruitment the scale must hold the

promise of an ultimate reward sufficiently high to makethe grade a career grade for those doctors who have tospend the remainder of their professional life in it and toattract into it suitably qualified general practitioners forpart-time work."

REVIEW AND REORGANISATION

The working party recommends that regional boardsand boards of governors should institute a review in the

light of the working party’s report, and should report tothe Minister proposals for (a) additional consultant

appointments regarded as necessary immediately, and (b)posts in the medical assistant grade. In framing their pro-posals the boards should examine carefully the possibili-ties of adopting the " firm " system more widely, and ofreducing time lost by consultants in travelling and inother unprofitable ways.The working party suggests that the Minister should

seek advice on the proposals for additional consultant

appointments and for the establishment of medical-assistant posts from a professional committee consisting ofmembers appointed by him and by the Joint ConsultantsCommittee.

After the introduction of the new grade, no furtherjunior hospital medical officers or senior casualty-officersshould be appointed.

THE "ARTIFICIAL MUSCLE" OF McKIBBEN

MARGARET AGERHOLMM.A., B.M. Oxon.

UNIVERSITY LECTURER IN ORTHOPÆDIC SURGERY

ALPHONSUS LORDRESEARCH ENGINEER, DISABLED LIVING RESEARCH UNIT,

MARY MARLBOROUGH LODGE

NUFFIELD ORTHOPÆDIC CENTRE, OXFORD

THE McKibben muscle, more commonly known as

the " artificial muscle ", is used in the U.S.A. to helpprovide some active movement for patients with severeflaccid paralysis of the upper limbs. This device wasinvented by Mr. J. L. McKibben, a Los Angeles physicist;and its use has been developed by Dr. Vernon L. Nickeland his team at Rancho Los Amigos Hospital, near LosAngeles.The " muscle " consists of an inner rubber tube contained

in an outer cover of double helical nylon weave. Inflation ofthe tube causes the " muscle " to shorten, and in so doing itdevelops a substantial mechanical pull. The strength of pullis varied by the amount of inflation. The " muscle " in fig. 1is 7 in. long. It is seen at rest and lifting a 7 lb. weight through13 /4 in.Carbon dioxide gas is used to inflate the " muscle ". Its

flow is controlled either by a system of mechanical valves or,for patients with very slight residual power, by an electrical

system inwhich micro-switches acti-vate D.C. gassolenoids.Both systemsoffer three

positions-"operate"," releaseand holdThe "hold"positionenables a con-traction to bemaintainedwithout tfurther volun-

tary effort,and withoutfurther con-

sumption ofcarbon dioxide.A gas cylin-

der, 7 in. longand weighingabout 171/4 oz.when full,usually lastsone " muscle "for 4-5 days,

Fig. 1-The McKibben "artificial muscle":shortened by inflation and lifting a 7 Ib. weight;and at rest.

and two " muscles " for half that period. It can be attached to

bed or wheelchair, or carried in the pocket. Patients can have a

cylinder-recharging equipment for use in their own homes,The " muscle " is remarkably durable and usually lasts for

many months: it is easy and cheap to replace.The commonest uses of the " artificial muscle " so far

have been to work a flexor hinged splint so as to give a" pinch " between the thumb and the first two fingers(fig. 2), and to help move a ball-bearing functional armsupport to give flexion and extension of the elbow.Other uses of its muscle-like properties can be devisedaccording to individual needs-e.g., to move a tray fromside to side to bring different objects within a limitedreach. Several " muscles " can be fitted to one patientto give different movements, provided sufficient residualpower can be found to work them. A patient can sometimescontrol three or four separate " muscles " with one foot.The use of the " artificial muscle " and the associated

splints, feeders, &c., requires not only a basic knowledgeof the management of paralysed limbs, but also technicaltraining in designing, making, and fitting these specialdevices to the individual limb, and in the education ofthe patient in their use. One of us (A. L.) has attended anintensive course at Rancho Los Amigos Hospital, andwork on these lines is now proceeding at Mary Marl.borough Lodge-the Disabled Living Research Unitwhich has been built in the grounds of this hospital with

Fig. 2-The " artificial muscle " acting on a rancho hinged 6tM!splint to give an effective " pinch ".